Chronic Pain Care Palliative Contract for Narcotic Medication Use

All patients on high dosage chronic opioid or narcotic therapy must sign and follow the contract shown below:

Your provider and yourself have elected to proceed with high dosage COT (chronic opioid or narcotic therapy). Currently there are 16,000 patients/year in the US dying from routine narcotic prescriptions – generally of the higher dosage requirements. Thus, the FDA, CDC, and formal pain management societies have placed extreme scrutiny on the practice of ROUTINE narcotic prescribing for chronic pain control. The issues have been the amounts prescribed, length prescribed, reasons for prescribing (clinical needs), efficacy, real/actual pain control, development of tolerance, and questionable evidence of long-term efficacy with use of lengthy narcotic scripts (months to years), functional level improvements (ability to dress, eat, walk, sleep, work, household chores, etc.) need improvements in addition to pain control for prescribing beyond recommended limits (below).

Presently the CDC (Center for Disease Control) recommends maintaining a chronic narcotic dosage limit of 50 mg of Morphine per day or its equivalents in other narcotic medications. 50 mg of morphine equivalent is equal to 33 mg of oxycodone, 50 mg of hydrocodone, or 10 mg of Dilaudid daily by mouth. Additionally, these organizations are highly recommending no other sedative-hypnotic medications ingested while taking narcotics. Prescribing beyond these narcotic script limits despite utilizing much larger amounts for extended periods may cause heart attack, stroke, near death, coma, or death. Therefore, in agreement with your medical provider and the need to administer > 50 Morphine mg equivalents/day to yourself, you have agreed by signing The Chronic Palliative Pain Control Contract that you are of the understanding that your health is at risk for heart attack, stroke, near death, coma or death. Additionally, use of any additional sedative pain control, sleeping or psychiatric medication (anti-depressant or anxiety medication) even though your narcotic dosage is under 50 mg of Morphine equivalents daily places your health at risk for heart attack, stroke, near death, coma or death.

Thus, your medical condition has placed you due to your narcotic and other sedative medication needs under a PALLIATIVE chronic pain control regimen. This means that your provider is treating a condition not likely to medically improve, and pain control using narcotic medications is one of the few viable clinical options. Failure to sign this form for your provider will necessitate your scripts be under 50 mg of Morphine or its narcotic equivalents (above). Failure to sign the form will eliminate any non-narcotic adjunctive medication such as Soma, benzodiazepines (Valium/Klonopin/etc.), antidepressant medication (i.e. Prozac), or sleeping medications such as Ambien when used with any amounts of narcotics prescribed. Potentially due to OSA (Obstructive Sleep Apnea) or other medical concurrent issues your health may be at risk for heart attack, stroke, near death, coma or death with chronic narcotic treatment at any dosage taken routinely. Thus, the use of narcotic pain medicine and/or sedative adjunctive medications with OSA or other identified serious medical condition places your health at risk for heart attack, stroke, near death, coma or death. This would be considered clinically needed palliative pain control care by prescribing narcotics and other sedative medications with an underlying serious medical condition.

I understand the implications of signing this form and wish to continue my present and recommended PALLIATIVE CARE Regimen of narcotics and adjunctive other sedative medications, if clinically needed. I do understand that the prescribing of narcotics and use of additional non-narcotic medications for my condition places myself at risk for heart attack, stroke, near death, coma or death. Any questions regarding this form, please ask your provider.